RICHARD WHITLEY, MSDirector

BRIAN SANDOVALGovernor

STATE OF NEVADADEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF WELFARE AND SUPPORTIVE SERVICESSTEVE H. FISHER

Administrator

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MEDICAID

Date:Case Name:Case ID:

PARENTAL REIMBURSEMENT QUESTIONNAIREOVERVIEW

The Nevada State Division of Welfare and Supportive Services requires parental financial responsibility for servicesprovided to disabled children. The Division is seeking a monthly reimbursement of Medicaid costs from parents who meetcertain financial thresholds. Consideration is given to family size and annual income. Credit is given when the child is caredfor at home and for private comprehensive health insurance premium payments. There is a family deduction amount anda deduction for paid child support.

This form must be completed by the parents of undefined undefined, a disabled child receiving Medicaid services throughthe Division as a resident in a medical facility or as a recipient of home care services. The information is used to determinehow much, if anything, the parents of this child are required to pay.

The completed form should be returned to the address above. Questions may be addressed to undefined at (702) 486-1646;(775) 684-7200; (800) 992-0900 ext 47200. Failure to return this form within fifteen days from the date it was mailed toyou may result in your being assessed $1,900 per month.

Remember, you are certifying to the correctness of your answers. The Division verifies the answers you provide on thisform. If you make a false or misleading statement, misrepresent, conceal or withhold facts to avoid financial responsibilityfor your child's Medicaid expenses, you will be assessed $1,900 per month.

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HOUSEHOLD INFORMATION

1. Home Address:

(Number & Street) (Apt.)

(City) (State) (Zip)

Mailing Address: (If different from the Home Address, if you have a box number, or if you live in a rural area or area difficultto find, give directions.)

(Number & Street) (Apt.)

(City) (State) (Zip)

(Home Telephone No.) (Cell Telephone No.) (Work Telephone No.)

2. List all persons living in your home; include yourself, your spouse and all children.

FIRSTLEGAL NAME

MI LASTRELATIONSHIP TODISABLED CHILD

SOCIAL SECURITYNO. DATE OF BIRTH

INCOME

3. You must provide proof of income by submitting copies of last year's income tax return, including all attachments. (If your currentsource of income is different from last year, submit proof of current income.)

RECEIVED BYNAME AND ADDRESS OF EMPLOYER,

COMPANY OR TRAINING FACILITY

DATE WORKBEGAN ORWILL BEGIN

DATES PAY ISRECEIVED OREXPECTED TOBE RECEIVED

HOURLYPAY

RATE

HOURSPER PAY-

CHECK

PAYFREQUENCY(WK/BI-WK/

MO/SEMI-MO)

GROSS PAY(BEFORE

DEDUCTIONS)PERPAY-CHECK(WK/BI-WK/SEMI-MO) TIPS

$ $ $

$ $ $

$ $ $

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OTHER MONEY INFORMATION

4. You must provide proof of income. (If you are self-employed, you must provide copies of your last two (2) Income Tax returns, withall attachments.)

RECEIVING?NO YES

RECEIVEDBY WHOM?

CLAIM NUMBER (IFYOU HAVE ONE)

AMOUNT (WK/MO/SEMI-MO)

1) SUPPLEMENTAL SECURITY INCOME (SSI) $ per

2) SOCIAL SECURITY INCOME $ per

3) VETERAN BENEFITS $ per

4)

RETIREMENT PENSIONS (CIVIL SERVICE, RAILROAD,MILITARY, PUBLIC EMPLOYEE-INCLUDE PRIVATE OR UNIONETC.)SOURCE: $ per

5)

DISABILITY PAYMENTS FROM ANY SOURCE (SIIS, REHABOR OTHER)SOURCE: $ per

6) UNEMPLOYMENT BENEFITS $ per

7) BOARDERS/ROOMERS $ per

8) INDIAN GENERAL ASSISTANCE $ per

9) MILITARY ALLOTMENT $ per

10) UNION ANNUITIES $ per

11)

INTEREST OR PAYMENTS (STOCKS, BONDS, TRUSTS, OILLEASES, ETC.)SOURCE: $ per

12) MONEY FROM PROPERTY RENTALS, LEASES, MORTGAGES $ per

13)MONEY FROM RELATIVES OR OTHERSNAME: $ per

14) STRIKE BENEFITS $ perMONEY RECEIVED FOR EDUCATION (BEOG/PELL, SEOG,NDSL, USAF, NSIG, VA, STUDENT LOAN, ETC.)SOURCE:

15) PERIOD COVERED: FROM: TO: $ per

16)INCOME GRANTS OR ASSISTANCE (COUNTY WELFARE,TANF OR FOSTER CARE, ETC.) $ per

17)ALIMONY PAID DIRECTLY TO YOURECEIVED FROM: $ per

18)ANY OTHER INCOME NOT STATED ABOVETYPE: $ per

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CHILD SUPPORT OBLIGATIONS

5. Complete each item below for child support payments made last year using last year's income. (If your current child support obligationis different from last year, submit proof.)

CUSTODIAL PARENTNAME CHILDREN'S NAME(s)

DISTRICTATTORNEY

CASE#CUSTODIAL PARENT

SOCIAL SECURITY NO.ANNUAL

AMOUNT PAID

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

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MEDICAL INSURANCE

6. My disabled child has hospital/medical/dental/school and/or accident insurance (Include group insurance programs through your pastor present employer or union and policies held by an absent parent or stepparent).

YES NO

Premium Amount $ Monthly Quarterly

Policy No. Group Policy No.

Name of Insurance Company

Insurance Company Address

Policy Holder Social Security No.

Coverage Effective Date

List other individuals covered under this policy.

7. I am or my spouse is a Veteran YES NOBranch of Service VA Claim No. VA Serial No.

8. Are any medical costs paid by another agency (SIIS or other)? YES NO

If YES, by whom?

OTHER PARENT

9. Is there an absent, deceased or disabled parent of the disabled child?NAME SOCIAL SECURITY NO. DATE OF BIRTH ABSENT DISABLED DECEASED

I/we certify that I/we gave complete and accurate information and I/we acknowledge willful concealment of income and householdinformation could result in criminal prosecution.

I/we acknowledge if false or misleading statements are made, misrepresentation, concealment or facts are withheld to avoid financialresponsibility, I/we will be assessed a monthly reimbursement of $1,900.

(All parents living in the household must sign.)

/ /Client Signature Print Name Date Telephone Number

/ /Client Signature Print Name Date Telephone Number